Coordinator Review Services

Coordinator Review Services

The Review Services Coordinator is a critical role in adjudicating pre-authorization coverage requests for all types of services - medical and DME. The work environment is fast paced and at many times complex. Knowledge of health plan functions is required and include reading and interpreting contracts and coverage and understanding claims payment. This role includes handling a high volume of incoming calls from members and providers, managing multiple requests simultaneously and accurately and easily identifying requests that require a higher level of clinical review. This position must have a strong knowledge of medical terminology, CPT, HCPC and ICD coding as well as strong computer skills. This position requires that all CMS, State and Federal compliance and regulatory requirements be met.

Essential Responsibilities:

• Adjudicate pre-authorization requests for all services - medical & DME. Determine urgency of request based on information provided. Enter & process selected patient medical information into the Referral Management System (RMS) to produce the authorization.
• Receive and process incoming phone calls from members, providers and internal KFHPW departments.
• Perform and research complex issues related to authorization denials, delays and claims related issues. Ability to get to the root cause of an issue and provide an accurate, concise explanation to the member, provider and/or internal KFHPW department.
• Other duties as assigned (eWatson, training, JIVA, Ring of Defense)

Basic Qualifications:

• Minimum two (2) years of health care experience with emphasis in health insurance including pre-authorizations, benefits/eligibility, and billing.
• Minimum two (2) years of experience with online computer systems and Microsoft Office.
• Minimum one (1) year of phone customer service experience.

Education:

• High School Diploma or General Education Development (GED) required.

Additional Requirements:

• Medicare and strong communication skills.
• Computer skills in Windows environment, including MS Word and Excel.
• Kaiser Foundation Health Plan of Washington applications.
• Communication and interpersonal skills.
• Working knowledge of Health Plan benefits and policies.
• Basic understanding of Medicare regulations, particularly those pertaining to the provision of Part B services.
• Working with the public with emphasis on problem solving and conflict resolution.

Preferred Qualifications:

• Kaiser Foundation Health Plan of Washington (KFHPW) work experience.
• Experience with health plan contracts & coverage.
• Health plan claims experience.
• Medical coding experience with ICD-9/10, CPT and HCPCS.
• Some college courses preferred.